Provider Demographics
NPI:1275620015
Name:GIBSON-BOLTON, CLARA DELORISE
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:DELORISE
Last Name:GIBSON-BOLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 DACCA DR.
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77047-1240
Mailing Address - Country:US
Mailing Address - Phone:713-738-3441
Mailing Address - Fax:
Practice Address - Street 1:2002 HOLCOMBE BLVD.
Practice Address - Street 2:RM. 3A-110
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4211
Practice Address - Country:US
Practice Address - Phone:713-794-7332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory